Category Archives: policy

“Preventive medicine” is a hot phrase in discussions of health reform. If we just get more people (why not everyone!) screened we can find disease early and save money by attacking these diseases before they become serious and expensive.

But this use of ‘prevention’ is expensive. Or said another way: There’s a lot of money to be made in this kind of ‘prevention’.

We must recognize that health screening technologies are not tools to prevent disease; rather, they are tools of early detection of disease. In a sense they define disease. Indeed as screening tools increase in specificity, the thresholds in defining disease status follow in their specificity. Certainly, early detection may give the upper hand to the patient and provider who can implement treatments that reduce the likelihood of that condition becoming life-threatening. But do all abnormalities warrant medical intervention?

Screening technologies such as MRIs are become increasingly sensitive to discovery. In his book How Doctors Think, Jerome Groopman, M.D., cites a physician: “The hateful part of MRIs – I mean they can be a wonderful technology – but they find abnormalities in everybody.” No doubt, part of the rise in the number of chronic conditions can be attributed to our increased ability to find abnormalities, even though not all abnormalities may warrant a medicinal response.

Screening tools do not and cannot prevent abnormalities. They can only find abnormalities.

The primary driver of health care costs is medical technology. Earlier detection coupled with expensive (yet often unproven) interventions have reduced mortality while increasing morbidity. Indeed, many diseases which even 15 years ago would have been a death sentence have now become manageable chronic conditions (HIV/AIDS is an obvious example). This is a testament to our ability to innovate and develop life saving technologies.

Simultaneously, technology has improved our ability to detect ‘disease’ while ensuring chronic care management through pharmaceuticals and/or invasive intervention through biopsies and more. Today, more than half of all Medicare beneficiaries have more than 5 chronic conditions. Soon it will not be uncommon for the bulk of Medicare beneficiaries to have eight or even ten chronic conditions.

The demands of the public for definitive wellness are colliding with the public’s belief in a diagnostic system that can find only disease. A public in dogged pursuit of the unobtainable, combined with clinicians whose tools are powerful enough to find very small lesions, is a setup for diagnostic excess… Clinical medicine can only say, “With the methods we used, we found none of the diseases we looked for.” No one can measure the absence of all disease. (emphasis mine)

The unfortunate reality is that it is possible to over ‘prevent’ (to use the expensive version of the word). What is needed is not a halt on innovation nor a moratorium on technology. Rather what is needed is a conscious assessment as to when to screen and when treatment is necessary.

The decision as to when to do what should be made between physician and patient, but information is needed to build suggestive guidelines. Health IT, allowing for the aggregation of (anonymous) data, can help.

Adding health IT to our current system and claiming that will solve our health care problem is like taking a 1971 Ford Pinto and giving it a new paint job and sound system. It looks cool. It sounds cool. But you’re missing the point.

Health IT can be and should be a piece of the health reform puzzle. And it’s one of the few- and perhaps the only puzzle piece that holds bipartisan support. Even accounting for the initial upfront costs, health IT is touted to save billions of dollars. (And recent new argument: It’ll create jobs.)

This CBO report lists how health IT can:
• Eliminate the use of medical transcription and allow a physician to enter notes about a patient’s condition and care directly into a computerized record;
• Eliminate or substantially reduce the need to physically pull medical charts from office files for patients’ visits;
• Prompt providers to prescribe generic medicines instead of more costly brand-name drugs; and
• Reduce the duplication of diagnostic tests.

In addition to the above mechanisms to cut wasteful care given, there is very little doubt that health IT can improve the quality of care given. From that same CBO report, health IT can:
• Remind physicians about appropriate preventive care;
• Identify harmful drug interactions or possible allergic reactions to prescribed medicines, and
• Help physicians manage patients with complex chronic conditions.
• All problems cost money to fix, so preventing these problems from occurring does save money.

In public circles, the common rhetoric is that this higher quality of care results in lower costs. And this is where I take issue.

Yes, healthy people cost less. If you don’t need a doctor, you don’t cost much (duh). But healthy people don’t undergo high quality care; they don’t undergo any care!

On the other hand, by definition, those with chronic conditions are in constant need of care. High quality care to this population means doing more tests and providing more care more often.

That’s because only 56% of those with chronic conditions receive the recommended level of care. So higher quality care means more care. And in our system built on a la carte financing, more care means more money. Now this a real problem!

Those with one or more chronic condition currently make up 75% of our health care costs. And that number will only rise. (Explaining why is a whole other post)

Health IT can help providers know what care needs to be provided in order to adhere to these standards. Many EMRs in place today force providers to go through check-lists while caring for a patient to ensure that everything that is ‘supposed to be done’ is in fact done. EMRs also allow providers to be proactive and give patients appointment reminders to increase quality (and quantity) of care.

Does this mean we should forgo implementation of health IT? Of course not! Health IT can help us reduce needless spending for needless care and increase needed spending for needed care. It’s just that in weighing these two, spending may prevail.

Health IT is a powerful tool. But we have to recognize its place among other tools on the tool belt.

Jason Shafrin, author of the Healthcare Economist blog, wrote an excellent one-page summary differentiating Obama’s and McCain’s strategies for healthcare reform: http://healthcare-economist.com/2008/08/18/obama-vs-mccain-health-care-policies/. Obama’s government-led plan focuses on creation of larger risk pools and compulsary health insurance for children and young adults. McCain’s plan is based on individual agency and free market principles.

If health is a right, as decided by the World Health Organization, and only governments can provide citizens with real rights, then the government must be involved in ensuring its population has the capability to access a basic package of health services. The healthcare system is fundamentally different than the marketplace, which means consumers interact with the healthcare system very differently. Some of the differences:

Information Monopoly – Consumers cannot easily make informed decisions about what services should be provided or how much they should pay for them.

Emergencies – Most consumers, especially sick ones, don’t have time or the knowledge to navigate the health care system to find the best deal. Obama said it very succintly: “When your child gets sick, you don’t go shopping for the best bargain.”

Insurance Pools – Insurance plans require large subscriber bases to spread risk and share costs. The private, state-specific insurance plans have not been capable of creating large enough pools to bring costs down.

False Competition – The open marketplace forces companies to compete for customers on prices and quality. In healthcare, companies compete for market shares but not in a way that improves quality. Costs are usually lowered at the expense of quality. Consumers will sacrifice on the comprehensiveness of their insurance plan for lowered premiums without realizing that the uncovered services statistically improve population health.

McCain’s plan would increase the number of insurance subscribers, but would also make the system more dependent on consumers understanding of their health needs and more dependent on market principles that simply don’t apply to health care.

Obama’s plan is initially more costly, but it will result in an even greater increase in insurance subscribers (especially among children and young adults), and moves responsibility for population health away from individuals and into the hands of the only entity that can provide basic rights to a population level: government.